Executive summary

At about 1721 on Wednesday 4 January 2006, the 41st wagon of Pacific National freight train 3AB6 derailed at a track misalignment at Yerong Creek, New South Wales. Eight wagons following the 41st wagon then derailed. There were no injuries. The track sustained significant damage and was closed for 48 hours.

The investigation found that the most likely cause of the derailment was a track misalignment which was caused by a combination of several factors any one of which may not have resulted in the derailment in its own right.

Rail Recommendations

[RR2008001] [RR2008002]

Rail Safety Advisory Notices

[RS2007003]

At about 1540 on 22 September 2006, a flash fire erupted in the high-pressure welding oxygen system on board Searoad Mersey. The trainee engineer received burns to his arms from the flashfire and from molten plastic impinging on his skin when the hoses ruptured. He was wearing overalls at the time, but the sleeves were rolled up. Consequently, the overalls did not protect his arms.

The fire occurred when the heat created by the compression of the oxygen within the system ignited a replacement hose that had been fitted into the system. The hose had a lining made from a material with a low ignition temperature that had been made in an oily environment. It was not fit for its intended purpose and did not comply with any standards for high pressure oxygen hoses.

The hose had been fabricated by a hose supplier who had not been trained about the hazards or standards associated with high pressure oxygen systems and had ambiguous information regarding the suitability of hose materials for the purpose. The report also found that the fixed oxy-acetylene system had not been inspected or maintained in accordance with marine orders.

The report makes several safety recommendations with the aim of preventing further incidents of this type.

Executive summary

At about 0530 on 11 November 2006, a fire started in the engine room on board the Antarctic supply ship L'Astrolabe. The fire was fed by a spray of diesel fuel from a leak that had developed in the starboard main engine fuel system.

The ship's crew closed the remotely operated, fuel system quick closing valves, which shut down all of the main and auxiliary engines, isolated all ventilation to the engine room and then operated the engine room's fixed fire extinguishing system.

By 0620, the fire had been extinguished and the crew worked to restart the ship's main and auxiliary engines. By about 1200, L'Astrolabe had resumed its passage to Hobart using its port main engine and, by 1030 on 12 November, the starboard main engine was also back in service.

The ATSB's investigation found that the fire was caused by a leak of diesel fuel, probably in the form of a spray, from a temporary blanking arrangement on the starboard main engine. The fuel ignited when it came into contact with the hot surfaces of the starboard main engine.

The report identifies a number of safety issues and issued one recommendation and three safety advisory notices.

Executive summary

At 1730 on 10 September 2006, the Hong Kong registered bulk carrier Creciente berthed in Port Hedland, Western Australia, to load a cargo of iron ore.

At about 0245 on 12 September, the almost fully laden ship broke away from the wharf under the influence of a strong ebb tide.

Despite the use of several tugs and the ship's engine, it was not possible to manoeuvre the ship back alongside the wharf. The harbour master decided to hold the ship in the deepest part of the port's entrance channel until the next high tide.

By about 0615 on 12 September, the ship was firmly aground in the channel and, at about 0950, it was successfully refloated.

The ATSB investigation found that the effective holding capacity of the ship's mooring winch brakes was reduced by the number of layers of mooring line on the winch drums and the poor condition of their brakes. The investigation also found that it was highly likely that the brakes had not been sufficiently tightened and that the mooring winches were not effectively monitored in the time leading up to the incident.

The investigation also found that neither the port authority nor the ship's master had identified the possibility of the ship breaking away from its berth and appropriately assessed the risks associated with this potential hazard.

The report issues two recommendations and five safety advisory notices to address the identified safety issues.

Executive summary

At 1400 on 28 August, Massive Tide departed Dampier with a load of bulk cargo for the drill rig Ensco 106. After clearing the berth, the master handed over the watch to the second mate who then remained in charge of the watch for the transit to the drill rig.

The master took over the watch when the ship reached the drill rig at 1950 and the second mate remained on the bridge to operate the bulk-board for the cargo transfer. After the completion of cargo operations, the master handed the watch back to the second mate and then went to bed.

At 0100 on 29 August, the ship departed the drill rig. The second mate checked the global positioning system (GPS) unit and then set the autopilot to follow a course of 129° (T). The weather was good with light winds, slight seas and visibility of about eight miles.

At 0200 and 0400, the second mate recorded the ship's GPS position in the deck logbook but did not plot either position on the navigational chart. At about 0400, the bridge lookouts changed watches, but the second mate decided to leave the chief mate in bed until the ship reached the Dampier Sea Buoy.

At 0445, Massive Tide was making good a speed of 9.8 knots when it grounded on the shoals approaching the western shore of Rosemary Island.

The crew were called out and checks of the ship, its machinery and the surrounding area revealed that no damage or pollution had occurred. Immediate attempts to refloat the ship were unsuccessful and plans were put in place to try again on the next high tide. At 1035, Massive Tide floated free without assistance.

The report identifies a number of contributing factors and makes recommendations to address them.

This investigation was carried out by the Australian Transport Safety Bureau (ATSB) utilising investigation information provided by the Maritime Administrator of the Republic of the Marshall Islands (International Registries).

On 10 April 2006, an able-bodied seaman (AB) was fatally injured when he was struck by a mooring line while operating a winch on the forecastle of Probo Bear during a shift ship operation.

The report identifies a number of contributing factors and makes recommendations to address them.

Executive summary

At about 1540 on 10 July 2006, while Enterprise was in Bass Strait, Australia, an alarm sounded indicating that the main engine lubricating oil pressure was low. When the duty engineer started changing over to a second filter, lubricating oil pressure was lost; causing the engine to stop and the ship to black-out. The engine was restarted and the passage was resumed.

At 1805, the main engine low lubricating oil pressure alarm sounded again. At 2000, after further inspections had been undertaken, the chief engineer advised the master that the main engine could not be run due to probable bearing damage and that the ship would need to be towed to the nearest port for repairs. The main lubricating oil pump was also found, at this time, to have failed.

The ship was towed into Melbourne, arriving on 15 July, where all main and bottom end bearings were inspected. A large gouge mark was found on one bottom end bearing.

Further investigations revealed that the gudgeon pin in number five piston had failed when a pre-existing, undetected flaw led to fatigue cracking of the gudgeon pin. The engine manufacturer had not provided sufficient guidance for monitoring the fatigue life of gudgeon pins or for inspecting gudgeon pins for cracks.

The investigation also found that maintenance planning for the main lubricating oil pump was inadequate in that maintenance was not undertaken according to the manufacturer's instructions, despite the fact that the pump had failed previously.

The execution of routine maintenance on the lubricating oil filter was also inadequate in that the spare filter was not ready for use. The shipboard procedures did not identify the error and the procedures for operating and monitoring the filter were also ineffective.

The report makes three recommendations to address the identified safety issues with the aim of preventing other similar occurrences.

Marine Recommendations

[MR20070027] [MR20070028] [MR20070029]

Executive summary

On 16 June 2006, during Kota Pahlawan's voyage from Singapore to Australia, a foul odour was noted coming from two containers on board the ship. The containers were packed with xanthates, dangerous goods which produce carbon disulphide vapours and can spontaneously combust.

Later that day, the master informed the ship's charterer of the 'incident' and that the odour indicated that the packaging of the xanthates was not 'gas-tight', in accordance with international rules. He also asked for the containers to be discharged at Brisbane, the ship's next port of call.

At 0411 on 18 June, the master reported the incident as a defect to the Australian Maritime Safety Authority (AMSA). At 0720, the ship embarked a coastal pilot and started its transit of the Great Barrier Reef.

At 0907 on 19 June, AMSA issued a defect report and started collecting information about the incident. At 1252, the pilot disembarked from the ship after it had completed its transit of the northern part of the Great Barrier Reef Inner Route.

The ship berthed in Brisbane on 22 June after an 'emergency' was declared in the port. All eight xanthates containers on board the ship were discharged and purged with nitrogen gas to mitigate the risks posed by the foul smelling, highly flammable and toxic carbon disulphide vapours. On 24 June, the master was asked to reload the containers. He agreed on the condition that AMSA provide a written acceptance of the proposal with regard to 'compliance' with international rules.

By 0400 on 25 June, the xanthates containers had been reloaded onto the ship before it sailed from Brisbane. On 6 July, the ship discharged the last of the xanthates containers in Fremantle.

The report identifies several safety issues and the safety actions to address them.

Executive summary

At 1400 on 1 May 2006, Crimson Mars sailed from Bell Bay, northern Tasmania with a local pilot on board. The sky was cloudy and the visibility was clear with a light south-easterly wind. During the ship's turn to port around Garden Island, at about 1440, starboard instead of port helm was applied for approximately one minute. The error was not noticed initially and by the time maximum port helm was applied at 1441, grounding was inevitable. Soon after, the pilot ordered both anchors to be let go and the main engine to be run at emergency full astern in an attempt to reduce the effects of the impact. At 1442, the ship grounded on Long Tom Reef as the port anchor was let go and the main engine run astern.

The ship, with its main engine running astern, moved off the reef and refloated at 1446. An attempt to retrieve the anchor resulted in the failure of the port windlass. The ship remained anchored until 1605 when two tugs arrived to assist. The anchor cable was cut and left in the river with the port anchor. The ship then returned to the Bell Bay anchorage with the assistance of the tugs.

An inspection of the ship revealed that it was severely damaged and that temporary repairs could not be carried out in Bell Bay. The ship's departure was delayed until contingency arrangements could be put in place. Crimson Mars sailed from Bell Bay on 12 May for Hualien, Taiwan, to discharge its cargo and carry out permanent repairs.

The report identifies several safety factors and makes recommendations to address them.

At 0958 on 6 April 2006, the mooring hawser attaching Dampier Spirit to the CALM  buoy at the Stag oil platform off Dampier, Western Australia, parted and forced the ship to put to sea as a cyclone approached.

Dampier Spirit's master had delayed making the decision to disconnect from the CALM buoy when a cyclone, centred 200 miles from the ship, was declared. His decision may have been delayed because of ambiguities in the company's decision guidelines; the procedures did not accurately reflect the ship's ability to sail away from danger; the Stag platform was still discharging crude oil into the ship's cargo tanks; and the ship had safely remained at the buoy during a previous cyclone.

After the ship had separated from the buoy, it had difficulty in manoeuvring away from the area because the performance of the ship was reduced by the 'slow steaming' fuel injector nozzles fitted in the main engine and by the build-up of barnacle and coral growth on the hull.

The ship was tracking towards Tryal Rocks until the wind eased, allowing it to sail into safer water. If Dampier Spirit had grounded on Tryal Rocks, its 12 100 tonnes of crude oil cargo may have been spilled into the sea, resulting in significant damage to the environmentally sensitive mangroves and turtle nesting grounds in the area.